Complications Associated with Catheter Ablation of Atrial Fibrillation in Current Practice: Insights from a Large, Real-World Collaboration

Background: Catheter ablation is a cornerstone treatment for symptomatic atrial fibrillation (AF) with major improvements in safety over time. However, rates of adverse events with use of current techniques in a contemporary quality-focused network remain undefined. Objective(s): Across a large, real-world sample, we sought to describe (1) rates of major, adverse events associated with catheter ablation of AF and (2) patient-level factors associated with complications. Method(s): Utilizing the REAL-AF collaboration, a registry of contemporary AF ablation procedures with granular patient, procedural and follow-up data comprised of cases from over 50 operators across academic and non-academic sites, we evaluated all patients undergoing their first ablation procedure from January 2018 - June 2022. Risk-adjusted analyses were conducted to evaluate the relationship between patient factors and complications. Result(s): Among 3144 patients (age 66.1 +/- 11.0 years, 42% female, 67.1% paroxysmal, 32.9% persistent) who underwent AF ablation, procedure-related complications (n =77) were identified in 65 patients (2.1%) with multiple complications occurring in 9 patients (0.2%). Most complications (n=70, 93.5%) occurred in the peri-procedural (within 30 days) period and 6.5% (n=5) after 30 days, the latter of which all represented vascular injuries (Figure). Major complications (18 of 72 peri-procedural complications, 25.0%) are defined, detailed, and associated data reported in the Figure. Unadjusted (16.0% without CHF vs. 33.3% with CHF, p = 0.045) and risk-adjusted (OR 2.8, 95% CI 1.03-7.60, p=0.045) analyses indicated history of CHF was associated with a composite outcome of major complications. Analyses of independent complications showed those who suffered from peri-procedural stroke (n=3) were of significantly greater age (77.3 +/- 5.5 years vs. 66.1 +/- 10.9 years, p=0.035). Risk-adjusted analyses showed history of vascular disease (OR 2.9, 95% CI 1.02-8.20, p=0.045) was associated with vascular injury (n=18). From 0-695 days post-procedure, 31 deaths occurred (unknown cause: 17, COVID-19 related: 4, heart failure: 2, cardiac arrest: 2). Conclusion(s): Major complications represent rare events among those undergoing AF ablation in current practice. Risk-adjusted analyses suggest a history of CHF is associated with major complications. Similarly, older age and a history of vascular disease are associated with stroke and vascular complications, respectively. [Formula presented]Copyright © 2023

Ultrasound of Covid 19

We present how we used ultrasound to improve our diagnosis of lung Covid 19 and use ultrasound to diagnose the complications of Covid 19. Ultrasound was more sensitive in detecting early Covid 19 than chest radiograph. The complications of Covid 19 include renal impairment, liver impairment and vascular complications, mainly large vessel venous thrombosis, including renal vein thrombosis. We are all suffering from post-viral fatigue but lessons can be learnt from this pandemic and the use of ultrasound.

Minimally Invasive Coronary Artery Revascularization During Current Pandemics, New Hope! - Our Experience in a Third World Country

Objective: Since the last decade, the notion of minimally invasive cardiac surgery (MICS) has gained worldwide rapid popularity. Bangladesh is not far from mastering this technique due to the increasing interest of both patients and surgeons. Meanwhile, during this COVID-19 era could it help patients, remains the main question. In this context, we have operated on a total of 523 patients from October 2020 to November 2021 including, 89 patients who were MICS and among them, 17 were coronary artery bypass grafting. Method(s): We have included all patients who underwent minimally invasive coronary artery surgery in our hospital from October 2020 to November 2021 irrespective of single (MIDCAB) / multi-vessel disease (MICAS) or combined valve replacement with coronary revascularization. Data were collected from the hospital database, telephone conversations, and direct clinic visits. All data were analyzed statistically and expressed in the form of tables. Result(s): In the last 14 months of pandemics we have operated on a total of 89 MICS patients, among them 10 were Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), 6 were double or triple vessels coronary artery surgery (MICAS), 1 patient underwent upper-mini aortic valve replacement along with coronary revascularization. One of our patients needed re-exploration for chest wall bleeding on the same day. Mean ICU and hospital stay in our series were less than conventional revascularization. There was no in-hospital or 30 days' mortality in our series. Conclusion(s): Cardiac surgery these days is headed toward less invasive approaches with the aid of technology, advanced instruments, and pioneer's lead. But from our in-hospital results we conclude that by avoiding median sternotomy, these minimal invasive revascularization techniques can provide hope to the patients by alleviating symptoms with restored vascularity, reduced morbidity, preventing sudden cardiac death. Health costs reduction with shorter hospital and ICU stay are the added benefits.

Depression in patients with cerebral microangiopathy.

Cerebral microangiopathy (CMA) is one of the significant causes of depression in the elderly. Close associations of the risk of developing depression with white matter hyperintensity, the presence of lacunar infarcts, and other markers of vascular disease are shown. The available data suggest that various vascular mechanisms, in particular, involvement of small vessels of the brain, generalized microvascular and endothelial dysfunction, metabolic risk factors, - are risk factors for the development of depression. Pathogenetic mechanisms include cerebral hypoperfusion and immune dysregulation. Depression is also a common complication of coronavirus infection, occurring both in the acute and post-COVID periods. The same mechanisms as in vascular depression are involved in the pathogenesis of the development of post-COVID depressive disorders. Given the complexity of the mechanisms of development of depressive disorders in patients with CMA, the presence of severe comorbid vascular pathology, antidepressants with an optimal ratio of efficacy and safety should be preferred. Agomelatine (Valdoxan) is one of such drugs.Copyright © 2023 Ima-Press Publishing House. All rights reserved.

Navigating Giant Cell Arteritis (Gca) Service during and Post Covid-19 Pandemic: An Audit of Gca Care at North Bristol Nhs Trust against the Bsr Quality Standards

Background/Aims GCA is a systemic vasculitis predominantly affecting the large vessels that requires prompt diagnosis and management. This clinical audit aims to study the impacts of COVID-19 pandemic on our GCA service and to identify areas for improvement to ensure good and safe practice amid healthcare crisis. Methods We audited referrals for suspected GCA from February 2021 until September 2022 and measured our patient care against the BSR quality standards. We performed retrospective data collection from digital care record systems and analysed our data using the IBM SPSS Statistics version 29. Results 106 patients with suspected GCA were included, 73% were female and the mean age was 70 years. 75% of the referrals were from primary care. Main presenting symptoms were headaches (95.7%), scalp tenderness (69.6%), tongue/jaw claudication (52.2%), visual symptoms (47.8%), constitutional symptoms (43.5%) and polymyalgic symptoms (21.7%). 33% of patients were diagnosed and treated as GCA. Mean CRP was 23.9mg/L and mean plasma viscosity was 1.89mPA. The mean referral-to-specialist review time has reduced to 1.6 days, compared with 2.7 days pre-pandemic. All patients had vascular ultrasound but only 7.5% had a temporal artery biopsy (TAB), compared with 41% pre-pandemic. Table 1 compares expected and achieved BSR quality standards. Conclusion Changes in work pattern during the pandemic meant that the time from referral to specialist review was significantly reduced, by implementing twice weekly registrar-led 'Hot' clinics and reserving ad hoc slot(s) in on-call consultant's clinics for GCA referrals. We have ramped up our vascular imaging capacity for vascular ultrasound during the pandemic in response to reduced surgical operating capacity for TAB. Strategies to address areas for improvement identified in this audit include: (1) clear and timely communication with referrer about steroid initiation and dosage, at the time of referral;(2) improving communication with primary care, emphasising need for urgent Ophthalmology input in patients with suspected GCA-related visual symptoms, through updating our regional GCA guideline for primary care;(3) standardising and implementing a GCA review proforma or checklist in our department to ensure that the BSR GCA care bundle is being implemented and addressed at the earliest opportunity. (Table Presented).

Long-lasting brain fog is related with severity clusters of symptoms in COVID-19 patients. Background: COVID-19 patients may experience lon-lasting symptoms from weeks to even months. Aim: to evaluate long-term cognitive impairment based on the severity

Background: COVID-19 patients may experience lon-lasting symptoms from weeks to even months. Aim: To evaluate long-term cognitive impairment based on the severity of symptoms of COVID-19 infection in a primary health system setting. Material and methods: From a database of 363 patients, 83 cases aged 47 +or- 15 years, (58% females) were selected from June to August 2020. In patients who survived the virus, 24 infection-related symptoms were collected to create three severity clusters (mild, moderate, and severe). The follow-up time was at least seven months. Comparing the first two clusters with the severe cluster, the existence of brain fog and risk factors (obesity, hypertension, diabetes, chronic lung disease, and hypothyroidism) were analyzed. Results: Thirty-one patients (37%) had persistent symptoms lasting up to 240 days. Fifty-one patients (61%) experienced brain fog. Concentration was affected by symptom severity (odds ratio [OR] 3.63, 95% confidence interval [CI] 1.26-10.46, p = 0.02). Short- or long-term memory loss was not affected. Moreover, symptom severity was related to brain fog (OR 3.16, 95% CI 1.05-9.51, p = 0.04). Patients with persistent symptoms had a concentration impairment associated with severity patterns (OR 24.3, 95% CI 1.73-340.11, p = 0.03). Conclusions: Brain fog is associated with symptom severity in COVID-19 survivors and lasts for more than eight months.

Challenges in the Diagnosis and Investigation of Giant Cell Arteritis during Covid- 19 Pandemic Restrictions: Does the Southend Pretest Probability Score Help to Guide Clinical Diagnosis?

Background/Aims During 2020-2021 many usual hospital services were affected as focus turned towards managing COVID-19. Elective outpatient surgery ceased and rheumatology staff were redeployed to covid wards. This reduced the availability of temporal artery biopsy (TAB) and temporal artery ultrasound (TAUS) to aid in diagnosing giant cell arteritis (GCA). The rheumatology team making diagnoses of GCA or not-GCA were doing so often based entirely on clinical and laboratory findings. We aimed to determine referral patterns and investigations for suspected GCA during the covid pandemic, compare diagnoses at 6 months after initial assessment and retrospectively apply the Southend Pretest Probability Score (PTPS) and correlate with the diagnosis of GCA or not-GCA. Methods We reviewed all electronic referrals for suspected GCA from July 2020 - June 2021. Clinical details and investigations reviewed. PTPS applied giving a result of low, intermediate or high probability of GCA. Results 84 referrals for suspected GCA over 12 months. 20 diagnosed GCA/ large vessel vasculitis (LVV), 64 not-GCA. Peak referral months Nov 2020 and April 2021 with 13 and 16 referrals. Lowest in October 2020 with 1 referral. 57 female, 27 male. Mean age 70.1 years. 19% male referrals diagnosed GCA, 26% female diagnosed GCA. All LVV and PMR diagnoses were female. 27 TAUS, 6 TAB, 7 PET, 13 CT, 3 MRI performed. 30 patients had no additional investigations. Of 20 GCA;14 had supporting investigations, 6 were clinical diagnoses. All GCA diagnoses were consistent at 6 months. One not-GCA case was subsequently diagnosed with LVV on CTPET. All other not-GCA diagnoses were consistent at 6 months. The PTPS was retrospectively applied based on available clinical information in all except 2 cases, and compared to GCA/not-GCA diagnosis and investigations undertaken. Conclusion Referral numbers for suspected GCA were higher than previous years however the number of actual GCA diagnoses was similar. With limitations on diagnostic investigations due to covid, diagnoses of GCA with and without additional tests were accurate at 6 months, and correlated with a high probability score. The PTPS is a therefore valuable clinical tool in the assessment of GCA. (Table Presented).

Esophageal Mucosal Calcinosis: A Rare Site of Calcium Deposition in End-Stage Renal Disease

Introduction: Calciphylaxis, otherwise known as calcium uremic arteriolopathy, is defined as calcium deposition around blood vessels in skin and fat tissue which occurs in 1-4% of patients with end-stage renal disease (ESRD). Calcium deposition in the esophagus is extremely rare;to date, there have been only 4 cases reported worldwide. We report the fifth case of esophageal mucosal calcinosis occurring in a young male with ESRD. Case Description/Methods: A 37-year-old Thai man with ESRD on peritoneal dialysis since 2005 presented with generalized weakness and odynophagia due to oral ulcers, resulting in poor PO intake. He denied drinking alcohol, illicit drug use, or smoking. On exam his abdomen was soft, non-distended, non-tender, without any guarding. Past medical history included hypertension and COVID-19 in January 2022. Laboratory tests revealed neutropenia and pancytopenia, hyperphosphatemia, and hypocalcemia. EGD revealed distal esophageal esophagitis and hemorrhagic erosive gastropathy. Biopsy showed ulcerative esophagitis with dystrophic calcification, consistent with esophageal mucosal calcinosis .No intestinal metaplasia was noted. Immunohistochemistry was negative for CMV, HSV1, and HSV2. The patient was treated with pantoprazole 40mg IV every 12 hours, Magic Mouthwash 5ml qid, and Carafate 10mg qid. He was transferred to a cancer center where he had a bone marrow biopsy formed which was negative. His symptoms resolved and the patient was discharged to home (Figure). Discussion(s): Esophageal mucosal calcinosis is extremely rare. It is due to a combination of factors involving acidosis and the phenotypic differentiation (and apoptosis) of vascular smooth muscle cells (VSMC) into chondrocytes or osteoblast-like cells. These changes, along with the passive accumulation of calcium and phosphate, induce calcification. Acidosis is well-known to promote inflammation of the arterial walls, releasing cytokines that induce vascular calcification. The benefits of treatment with sodium thiosulfate remain unclear. An ample collection of cases should help devise standardized treatment options and establish management guidelines for this condition.

Mechanisms of impaired gas exchange following hospitalisation for severe COVID-19

Introduction/Aim: Reduced carbon monoxide diffusing capacity (DL CO) is common after recovery from severe COVID-19 and cohort studies have found it to be more abnormal than either VC or TLC. There is no specific evidence that this relates to membrane disfunction or vascular injury. Concurrent measurement of nitric oxide diffusing capacity (DL NO) and DL CO can be used to partition gas diffusion into its two components - membrane conductance (D m CO) and capillary blood volume (V C). In this study, we sought to evaluate D m CO and V C in the early and later recovery periods after severe COVID-19. Method(s): Patients attended for post-COVID outpatient clinical review and complex lung function testing including DL NO /DL CO (Hyp'Air;Medisoft, Leeds). Further appointments and repeat testing occurred when indicated. Lung function comparisons were made using t-tests. Result(s): 46 (8 female) subjects (mean+/-SD age 58+/-13, BMI 34+/-8), who had severe COVID pneumonitis, WHO ordinal severity classification of 6+/-1 and prolonged (19+/-22 days) length of hospital stay, were assessed 51+/-29 days post discharge. Mean TLC [z-score -1.64+/-1.31] and D L CO [z-score -1.60+/-1.48] were both reduced. V C and D m CO were reduced to a similar extent (Z-score -1.36+/-1.19 and -1.14+/-1.06, p=0.4). 14 (1 female) patients returned for testing 70+/-35 days later. In this subgroup, D L CO improved but remained below LLN (Z-score -2.98+/-0.73 [Visit 1] Vs -2.17+/-0.69 [Visit 2], p=0.01). D m CO improved (Z-score -1.99+/-0.91 Vs -1.25+/-1.17, p=0.01) but V C was unchanged (Z-score -2.33+/-0.53 Vs -2.03+/-0.76, p=0.17). Conclusion(s): Gas exchange is persistently abnormal after severe COVID. Membrane conductance is abnormal in the earlier recovery phase but improves to a significant extent. In contrast, reduced capillary blood volume persists. Repeat testing at longer intervals after recovery from acute illness is still required but these data raise the possibility that persisting effects of acute vascular injury will contribute to physiological impairment long after severe COVID pneumonitis.

Multi-scale Mechanisms of Maxing Shigantang in Treating Pneumonia Based on Transcriptomic Data.

Objective: Pneumonia is an infectious inflammation of the alveoli,distal airway,and interstitium caused by bacterial,viral,and other pathogens. Maxing Shigantang,originated from Treatise On Cold Damage Diseases,is a classic prescription for treating pneumonia,with significant clinical efficacy. However,its treatment mechanism is still elusive. Method(s): In that paper,the transcriptome-based multi-scale network pharmacology was used to reveal the overall pharmacological mechanism of Maxing Shigantang in treating pneumonia from six scales of tissue,cell,pathological process,biological process,signaling pathway, and target. Result(s):At the tissue level,Maxing Shigantang mainly acted on the focal tissue of pneumonia-lung and the main inflammatory immune tissues-blood and spleen. Analysis of cell,pathological process and biological process suggested that Maxing Shigantang could treat pneumonia by reversing inflammatory and immune functions and improving cardiopulmonary and vascular injury caused by pneumonia. Analysis of signaling pathway and target showed that Maxing Shigantang regulated inflammatory immune response pathways such as "coronavirus disease-COVID-19" and "Toll-like receptor signaling pathway",and related targets such as "MAPKAPK3" and "NRG1". Conclusion(s):This paper,from molecular to tissue levels,indicated Maxing Shigantang treated pneumonia mainly by regulating inflammatory immune response and improving cardiopulmonary and vascular injury.Copyright © 2023, China Academy of Chinese Medical Sciences Institute of Chinese Materia Medica. All rights reserved.

Risk of Retinal Vascular Occlusion among Patients with Covid-19 and Influenza A: A Multi-Centered Analysis

Purpose of Study: Severe COVID-19 infection has been associated with a hypercoagulable state, contributing to the formation of clots. Retinal vascular occlusion (RVO) is a common cause of vision impairment and is due to blockage of the retinal arteries and veins. There have been reported cases of patients with previous history of COVID-19 presenting with new RVO. Given the minimal research delving into this relationship, the purpose of this study was to investigate the short-term prevalence and risk for RVO following infection by COVID-19 compared to Influenza A. Methods Used: Two cohorts were created using TrinetX, a national federated electronic health record (EHR). The two cohorts consisted of patients with a history of COVID-19 (n=2,352,475) and patients with a history of Influenza A (n=67,065). Both cohorts were balanced using 1:1 propensity score matching (PSM) addressing demographics and medical comorbidities. Outcomes between the two cohorts were compared using adjusted risk ratios (aRR), with a confidence interval of 95%. Summary of Results: After PSM, two cohorts of 67,063 patients each were compared. Patients in the COVID-19 cohort had an average age of 41.4+/-23.0 years compared to 34.4+/-27.7 years in the Influenza cohort. Between the two cohorts, there was no significant difference in risk of developing retinal vascular occlusion (aRR [95% CI] = 0.72 [0.49,1.06];p=0.097) and patients with COVID-19 had a significantly lower risk for developing retinal vein occlusion (aRR [95% CI] = 0.45 [0.27,0.77];p=0.03). Incidence of retinal vascular occlusion was 0.1% between both cohorts. Retinal artery occlusion was excluded from analysis due to obfuscation of the data by the EHR. Conclusion(s): Between the two cohorts, there was no significant difference in risk for developing RVO within 120 days. However, while there was no significant difference, vascular occlusions were found at a relatively younger age than the general population. Although incidence of RVO was low between the two cohorts, both viruses could be considered a risk factor for development of RVO, particularly in younger patients lacking classic risk factors for the disease.

Mechanisms of impaired gas exchange following hospitalisation for COVID-19

Introduction/Aim: Reduced carbon monoxide diffusing capacity (DL CO) is the most prevalent lung function abnormality post COVID-19 infection. Two studies suggested this relates to alveolar unit loss with preserved capillary blood volume. The measurement of nitric oxide diffusing capacity (D L NO) concurrently with D L CO allows for the quantitation of the membrane component of gas diffusion (D m CO) and capillary blood volume (V C). We sought to monitor D m CO and V C in the recovery period of patients hospitalised for severe COVID-19. Method(s): Patients attended outpatient clinical review and lung function testing including DL NO /DL CO (Hyp'Air;Medisoft, Leeds), with further appointment if indicated. Lung function comparisons were made using t-tests and clinical associations using Pearson correlation. Result(s): 46 (8 female) patients (mean+/-SD) (age 58+/-13, BMI 34+/-8), were assessed 51+/-29 days post discharge. WHO ordinal severity classification was 6+/-1, suggesting severe disease, with prolonged (19+/-22 days) length of admission. V C and D m CO were similarly reduced (Z-score -1.36+/-1.19 Vs -1.14+/-1.06, p = 0.4). V C was negatively correlated with length of stay (r=-0.42, p < 0.01). TLC (Z-score -1.64+/-1.31) and D L CO (-1.60+/-1.48) were significantly reduced and negatively correlated with length of stay (r>-0.41, p<=0.02). WHO severity negatively correlated with TLC only (r=-0.45, p < 0.01). Demographic and biochemical data did not correlate with lung function.14 (1 female) patients returned for repeat testing 70+/-35 days later. D m CO improved (Z-score -1.99+/-0.91 Vs -1.25+/-1.17, p = 0.01). V C was unchanged (Z-score -2.33+/-0.53 Vs -2.03+/-0.76, p = 0.17). D L CO improved but remained below LLN (Z-score -2.98+/-0.73 Vs -2.17+/-0.69, p = 0.01). Conclusion(s): Similar reductions in D m CO and V C following hospitalisation for COVID-19 were identified. In those who returned for repeat testing, D m CO values normalised, but V C did not improve. Abnormal lung function related to increasing severity and length of stay. These findings suggests vascular injury may play a more important role rather than alveolar unit loss as the primary contributor to gas exchange impairment following COVID-19.

COVID-19 disease and hereditary angioedema

Since December 2019, an outbreak of a novel coronavirus (SARS-CoV-2) infection causing COVID-19 disease has influenced the whole world. Angiotensin converting enzyme 2 (ACE2) receptors on type 2 pneumocytes in humans were determined as the entry for SARSCoV-2. Receptor binding and subsequently endocytosis of ACE2 diminish the cell membrane expression and also the function of ACE2. ACE2 is an enzyme involved in bradykinin metabolism. Lys-des-Arg9-BK occured with enzymatic cleaving of Lys-BK derived from low molecular weight kininogen is inactivated by ACE2 in tissues and it is a vasodilator agent having its own receptor named bradykinin B1. Non-metabolized Lys-des-Arg9-BK can be the reason for tissue vasodilation and increased vascular permeability in the patients with COVID-19. Increased bradykinin levels in patients with hereditary angioedema with C1-INH deficiency (C1-INH-HAE) do not cause increased SARS-CoV-2 infection or more severe disease. Although SARS-CoV-2 infection does not result in increased bradykinin levels, it can increase Lys-des-Arg9-BK levels.Copyright © 2020 Bilimsel Tip Yayinevi. All rights reserved.

'Breaking' news: A pediatric case of leukocytoclastic vasculitis after SARS-CoV-2 vaccination

Case report In May 2021, the European Medicines Agency (EMA) approved the administration of the mRNA BNT162b2 vaccine (Pfizer/BioNTech) in adolescents aged 12-15 years, in the form of a two-doses-primary course three weeks apart, with a booster dose after five months. Few adverse events have been observed in vaccinated children -mainly fever, myalgia, or local edema at the injection site. Conversely, delayed cutaneous reactions are little reported in adults and even rarer in pediatric age. A 12-year-old boy, with no previous cutaneous or autoimmune diseases nor allergic reactions to previous vaccines or drugs, came to our attention because of a cutaneous rash, which started on his right arm two days after his first dose of Pfizer/BioNTech vaccine. The rash was flat, erythematous, and purpuric, with subsequent bruise appearance and spontaneous resolution. Lesions took over on the front side of his arms and shoulders until a month after the vaccine. Urine and blood tests -including blood cell count, flow cytometry, plasma biochemistry, inflammatory index, autoantibodies, coagulation, and platelets aggregation test -did not show significant alterations. Grass pollen monosensitization was detected. Biopsy of the lesions showed 'modest perivascular lymphohistiocytic infiltrate and focal infiltration of vascular walls with swollen endothelium' with 'occasional eosinophils, scattered neutrophil granulocytes, and erythrocytes in interstitial areas,' compatible with leukocytoclastic vasculitis. Epidermidis was undamaged, and the direct immunofluorescence showed fibrinogen deposits in superficial-to-middle dermis vessels. Further tests highlighted a high immune response to the vaccine without previous Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. No therapies were needed, and the boy experienced no other side effects undergoing his second dose. Few leukocytoclastic vasculitis cases after SARS-CoV-2-vaccination have been reported in adults, primarily flares of previously known vasculitis. A role for induced spike glycoprotein as a pseudovirion docking to specific vascular receptors has been suggested, too. To our knowledge, no similar cases were described currently, neither in such young patients nor with such atypical, focal lesions. Further studies are needed to identify the pathogenesis and possibly prevent the onset of this adverse reaction.

A Case of Post Covid-19 Endotheliitis

A 49-year-old man presented with shortness of breath and fever. He was in diabetic ketoacidosis on admission and tested positive for COVID-19 on PCR. He became bacteraemic with streptococcus pneu- moniae secondary to a super-added left lower lobe pneumonia. He developed new heart failure felt to be secondary to myocarditis, evidenced by a resolving ejection fraction throughout his admission and an unremarkable cardiac MRI. After developing confusion on the ward, a CT head and MRI brain identified a spontaneous frontal haematoma and multiple micro-haemorrhages throughout the cerebral hemi- spheres, cerebellum and the pons. Repeat MRI brain with diffusion weighted imaging identified multiple silent infarcts in the small vessel territories. Bacterial endocarditis was excluded with Cardiology input and hypoperfusion also excluded based on normotension throughout admission. The case was discussed at the Encephalitis and Neurovascular MDT meetings where MRI vessel wall imaging was reviewed and felt to represent a post-infectious endotheliitis. He was treated with intravenous methylprednisolone for 3 days and a further 5 days, due to new silent infarcts on a subsequent MRI brain, before a 10 week oral steroid taper. Multi-system complications from COVID-19 are not limited to those in the intensive care unit or with severe respiratory illness.

Covid-19 infection and cutaneous manifestations in the pediatric population

Background: COVID 19 infection in children is characterized by a clinical polymorphism, cutaneous manifestations being present in a significant percentage. Data reported in the literature described cutaneous manifestations in the form of measles rash, acral lesions, livedo reticularis and racemosa, acute urticaria, non-pruritic papulo-vesicular rash but also multisystemic inflammatory syndrome. Recognition of these lesions may suggest a diagnosis of acute SARS-COV2 infection, and when anamnestically detected, the rash provides evidence of a possible MIS-C in children that may quickly progress unfavorably. In some cases, newborns who belong to mothers affected by the new coronavirus have a temporary maculopapular rash, with a diffuse appearance, which disappears spontaneously but with an impact on the fetus. Method(s): In conducting this retrospective study we used data extracted from 320 medical records of pediatric patients diagnosed with acute SARS-COV 2 infection, in the Clinical Emergency Hospital for Children 'Sf. Maria' Iasi, Romania, between January 2020 -January 2021. Subsequently, the cases with cutaneous manifestations detected at the time of admission but also those present prior to admission and reported by the parents were selected. There were 3 pregnant patients who met the above criteria. Result(s): Cutaneous manifestations were present in 31% of patients. These had a favorable outcome in most cases. There were 7 cases of MIS-C in which the outcome was unfavorable (2 cases) and slowly favorable (5 cases). In these situations, the cutaneous manifestations lasted longer and in most cases, correlated with the severity of the disease. In pediatric pregnant patients, the outcome was favorable and did not have a negative impact on the newborn. Conclusion(s): Cutaneous manifestations are common in children with acute SARS-COV 2 infection and these appear to be represented by the location of the virus in the superficial blood vessels. The appearance of livedo-type lesions has been associated with microthrombotic processes and have been less frequently found but with a slowly favorable outcome. The diagnosis of MIS-C represents an emergency, cutaneous manifestations playing an important role in the early detection and treatment of these children.

Occlusive Explosion

Clinical Information Patient Initials or Identifier Number: A Relevant Clinical History and Physical Exam: 47yr old man, suffered a blast injury at the workplace after an O2 tank exploded while he was transferring liquid gas into a tank for welding purposes. The impact has caused him to temporary loss of consciousness. Upon awakening, he had severe chest pain associated with shortness of breath. On examination, superficial partial thickness injury on the chest wall, and lungs: reduced breath sound bi-basally, no murmur heard. BP:106/77mmHg, HR:100/min, SPO2 100% on HFM 15L/min. [Formula presented] [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: Serial ECGs were done and showed dynamic changes in the anterior leads Bedside echo before invasive coronary angiograms shows mild LVSD, normal valves, and no pericardial effusion [Formula presented] [Formula presented] Relevant Catheterization Findings: Right radial approach 6F system Opitorque catheter for diagnostic angiogram LMS: smooth LAD: ATO mid LAD, DG1 prox ATO LCx: smooth RCA: smooth Impression: ATO to LAD and Diagonal 1 ( Dual ATO) [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Right radial coronary angiogram via 6F system EBU 3.0 engaged with good support Sion blue wired into LAD, export catheter delivered, and aspirated red thrombus Pre-dilated with Sapphire 3 SC 2.5x15mm @ 6-10ATM Flow established in LAD, however, decided to interrogate DG1 as it shows ATO BMW wired into the DG1 and pre-dilated with Sapphire 3 SC 2.0x15mm Noted nonflow limiting dissection and decided to stent DG1 with 2.25x34mm@12ATM, dissection sealed and TIMI III flow established Stented mid LAD with 2.5x30mm @12ATM just before LAD/DG1 bifurcation, then stented proximal LAD with 2.5x 26mm@ 12ATM. Post-dilated LAD with 2.75x15mm@ 14-20ATM TIMI II-III flow IV Tirofiban has been given a loading dose due to a high thrombus burden and sluggish flow [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Myocardial infarction is a rare complication of blunt chest trauma. This case demonstrates how blast shock waves result in the dissection of the coronary vessel leading to total occlusion of the two vessels. It also promotes red thrombus within the coronary vessels. Percutaneous coronary intervention is the most suitable way to treat this condition. Intravascular imaging such as IVUS or OCT would be beneficial to demonstrate the physiology behind this MI and would also be helpful in planning and optimizing the lesions. Unfortunately, intravascular imaging was not used for this patient to reduce procedural time as he was treated during the height of the COVID pandemic.Copyright © 2023

The effect of COVID-19 on vascular elasticity and liver function in overweight patients.

Objective. To study the changes in the vascular wall, vascular age and metabolic parameters in polymorbid COVID-19 conva-lescents. Material and methods. The study included 62 patients with hypertension who reached the target blood pressure (BP) with dual an-tihypertensive therapy after severe and extremely severe COVID-19. The following examinations were performed: laboratory tests of metabolic parameters, assessment of changes in the vessel elasticity indices (pulse-wave velocity (PWV), augmentation index (AI), central systolic BP (cSBP), 24-hour BP monitoring, and non-invasive markers of liver fibrosis. Results. According to office BP measurements, after the coronavirus infection, an increase in systolic BP (SBP) by 29.6% and di-astolic BP (DBP) by 23.6%, as well as heart rate (HR) by 11.8% (p<0.05) was reported during regular antihypertensive therapy. In addition, 24-hour BP monitoring data indicated an increase in the average daily SBP, DBP, and heart rate. After the coronavirus infection, an increase in PWV by 35.4% (p<0.05), AI by 24.4% (p<0.05), cSBP by 22.1% were reported. Carbohydrate and lipid metabolism parameters deteriorated. A pronounced adverse effect of coronavirus infection on liver function was observed. The vascular age (according to the modified SCORE scale) increased by 6 years (p<0.05). Conclusion. Our study showed that patients after severe and extremely severe COVID-19 have a high risk of liver fibrosis, hypertension and lipid metabolism control worsening and accelerating vascular aging.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

Leukocytoclastic vasculitis following immunization with COVID-19 vaccine

Case report Introduction: Vaccines have been recognized as agents associated with development of different forms of vasculitis. We describe the case of a leukocytoclastic vasculitis which developed after immunization with inactivated COVID-19 vaccine. Case presentation: A 68-years old female patient presented with painful purpuric papules and plaques, and areas of necrosis, dominantly localized on her feet (Figure 1), developing 12 days after she received first dose of inactivated COVID-19 vaccine (BBIBP Cor-V). There were no other symptoms except mild fatigue and low-grade temperature of 37.3degreeC. Skin biopsy showed damaged vessel wall with perivascular, neutrophilic inflammatory infiltrate, leucocytoclasia and erythrocytes extravasation (Figure 2). Thorough work-up, including broad immunoserological and virological analysis didn't reveal any other potential trigger. Three months before vaccination the patient recovered from COVID-19 pneumonia. After the four weeks course of prednisone (initially 20 mg/day) with tapering a complete resolution of skin changes was achieved. The patient was followed for one year with no relapses. Conclusion(s): COVID-19 immunization should be considered as a potential trigger for development of cutaneous vasculitis.